Eating healthy is sound advice even for those who have already had a heart attack or who are at risk for cardiovascular events, researchers found.

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Patients with known cardiovascular disease, or diabetes with end-organ effects, were found to have a lower risk of a composite endpoint of cardiovascular death, MI, heart failure, or stroke if they consumed a healthy diet.

Note that the beneficial effect of a healthy diet compared with a less healthy one was seen irrespective of taking or not taking effective secondary prevention medications.

Eating healthy is sound advice even for those who have already had a heart attack or who are at risk for cardiovascular events, researchers found.

In an analysis of two cohorts of patients with cardiovascular disease or diabetes, those who had the healthiest diet had a significantly lower risk of further cardiovascular events than those whose ate the poorest quality diet (HR 0.78, 95% CI 0.71 to 0.87, P≤0.001), Mahshid Dehghan, PhD, of Hamilton General Hospital in Ontario, Canada, and colleagues reported online in Circulation.

The benefits were seen regardless of the type of medications patients were taking, suggesting that eating healthy can offer advantages on top of those of proven drugs such as aspirin, angiotensin modulators, lipid-lowering agents and beta blockers, the researchers wrote.

Several trials have shown the advantages of a healthy diet in patients who don't have prior heart disease, but there are few studies looking at the effects of diet on cardiovascular outcomes in people who already have health issues.

So the investigators looked at that relationship in two cohorts of patients who already have heart disease or diabetes with end-organ damage and who are taking drugs to treat their conditions.

The 31,546 patients, who had a mean age of 66.5, were either from the Ongoing Telmisartan Alone and in Combination with Ramipril Global End Point Trial (ONTARGET) or the Telmisartan Randomized Assessment Study in ACEI Intolerant Subjects with Cardiovascular Disease (TRANSCEND).

A food frequency questionnaire was used to assess dietary intake, and the researchers used two dietary indexes to assess diet quality -- the modified Alternative Healthy Eating Index (AHEI), an a priori approach, and the Diet Risk Score (DRS), an a posteriori approach.

The primary endpoint was a composite of cardiovascular death, MI, stroke, or congestive heart failure.

During 56 months of follow-up, there were 5,190 events.

Overall, the researchers saw a graded association between diet quality and the recurrence of cardiovascular events.

In adjusted models that controlled for several risk factors including body mass index (BMI), blood pressure, and stroke, as well as medications patients were taking, patients in the healthiest quintile of the AHEI had significantly lower risk of cardiovascular events compared with those in the lowest quintile (HR 0.78, 95% CI 0.71 to 0.87, P≤0.001).

They also had significant reductions for other individual outcomes between the highest and lowest quintiles (P<0.001):

Cardiovascular death: HR 0.65, 95% CI 0.55 to 0.75

Congestive heart failure: HR 0.72, 95% CI 0.58 to 0.88

Stroke: HR 0.81, 95% CI 0.67 to 0.98

The relationship with myocardial infarction was of borderline significance (HR 0.86, 95% CI 0.72 to 1.03).

The researchers emphasized the fact that a high-quality diet was associated with a consistent benefit regardless of the use of proven secondary prevention measures including aspirin, beta-blockers, and statins.

"From this we can infer that patients may derive an additive benefit when dietary modification is combined with proven drug therapies and other lifestyle changes," they wrote.

They added that similar effects were seen for the primary composite outcome and for individual components when diet quality was measured by the DRS.

These findings are consistent with several other studies that assessed diet quality in primary prevention settings, as well as with the "few existing studies" looking at the Mediterranean diet in secondary prevention of cardiovascular events, the researchers wrote.

The study was limited by its observational nature, and by its reliance on the use of the food frequency questionnaire to assess dietary intake.

Still, the researchers concluded that better diet quality is associated with a lower risk of recurrent or new cardiovascular events in patients with prior heart disease or diabetes, and that clinicians should emphasize the importance of healthy eating in this population.

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